Salaried doctors, on average, generate fewer RVUs than productivity based doctors. The question of whether that increased productivity leads to better care is endlessly debated by the wonks in the chocolate factory. Some folks believe that all physicians should be salaried to minimize economic incentives in health care. Again, that comes with benefits and risks to patients and unintended consequences that are under appreciated.
In some cases, providers noted that computer systems hid some of the information; if only three comments could be viewed per screen, they had to click to get to another screen, requiring them to search for information that might demand immediate attention.The study also found that there were fewer visual cues with the computational system. Some providers noted that they used to be able to get a sense of the status of the emergency department just by walking through the room and visually checking the manual whiteboard. “Without that public display, providers have to sit down at the computer and check it, which can add time or reduce awareness,” said a principal investigator.These are potentially disastrous consequences in an ED environment where patients can be highly unstable and serious events transpire rapidly and irreversibly. An investigator in the study observed that "the results provide an important case study of what can happen when new technologies are developed without sufficient understanding by designers of the nature of the work in which they will be used."This last observation raises a more fundamental question: why does such an axiomatic, common-sense statement, especially in a domain as complex as medicine, need to even appear in print?
Patient care information systems like CPOE ... can create unintended or "silent" errors, according to a separate study conducted by the same author in the Netherlands and Australia."Many information systems simply don't reflect the health care professional's hectic work environment with its all too frequent interruptions from phone calls, pages, colleagues and patients. Instead these are designed for people who work in calm and solitary environments. This design disconnect is the source of both types of silent errors …Some patient care information systems require data entry that is so elaborate that time spent recording patient data is significantly greater than it was with its paper predecessors," the authors wrote. "What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician."
“The problems are multiple—the presentation of information is often confusing or invisible, the pull-down menus don’t always make sense,” says Ross Koppel, PhD, who serves on the faculty of the University of Pennsylvania and has studied and written about CPOE extensively. “The alerts that come are almost always overwritten. They’re written by the legal team who don’t want to get sued for anything, so they warn of every drug interaction...”Physicians who suffer “alert fatigue” sometimes overlook something, or the alerts miss potential problems they should have caught. The CPOE interfaces look like “the state of art, circa 1992,” in part because they were developed on an accounting software platform and their development hasn’t yet achieved that of clinical systems, Koppel says.The user interfaces create a “hostile user environment” and are often difficult to read and easy to populate with misinformation, says Scot Silverstein MD, adjunct professor at Drexel University’s College of Information Science and Technology and a healthcare journalist. The confusing user interfaces “actually promote user error,” he says. “Some of these interfaces are guaranteed to cause user confusion and create mistakes—not just CPOE but other (IT) systems, as well...”[CPOE vendor contracts require physicians to] sign non-disclosure agreements prohibiting them from publicly discussing problems with the software. Physicians can tell a colleague about a problem they have been having with CPOE, but contractually they cannot publicly present that information at conferences or bring it up in online discussion groups...
HEALTH CARE INFORMATION TECHNOLOGY (HIT) vendors enjoy a contractual and legal structure that renders them virtually liability free—“hold harmless” is the term of art—even when their proprietary products may be implicated in adverse events involving patients. This contractual and legal device shifts liability and remedial burdens to physicians, nurses, hospitals, and clinics, even when these HIT users are strictly following vendor instructions. Vendors avoid liability by relying on the legal doctrine known as “learned intermediaries” and on warranties prohibiting claims against their own products’ fitness. According to this doctrine and legal language, HIT vendors are not responsible for errors their systems introduce in patient treatment, because physicians, nurses, pharmacists, and health care technicians should be able to identify—and correct—any errors generated by software faults...Vendors retain company confidential knowledge about designs, faults, software operations, and glitches. Their counsel have crafted contractual terms that absolve them of liability and other punitive strictures, while compelling users’ nondisclosure of their systems’ problematic, even disastrous, software faults...
Leapfrog’s Binder says hospitals “tend to be prehistoric in their thinking” when it comes to healthcare IT, and their vendors have not put interoperability in the forefront of product design. Other industries embrace technology and allow it to work across national and international systems, but some CPOE applications can only talk to themselves......scholars say the “hold no harm” clause should be removed, a move that would quickly improve the software, and the government could prohibit vendors from requiring physicians to sign confidentiality oaths. Providers should be able to share best practices, problems, and data with others using the same software across the country, not just with colleagues down the hall.
A week after reporting that use of electronic health records lowered the cost of care for its customers between 17 and 33 percent, Blue Cross Blue Shield of Rhode Island has backtracked on those claims. In an email sent to FierceEMR, BCBSRI says that while the program significantly improved healthcare quality, its cost data had not been risk adjusted and did not include costs related to infrastructure spending. "At this time we are unable to accurately ascertain the cost implications of the pilot and are retracting the news release..."
EHR contracts contain an increasing array of complicating structures and dense terms that offer fewer and fewer commitments to your practice. The problematic terms include:Broad disclaimers further distance EHR vendors from any responsibility or liability that may result from the use of their products regardless of the cause:Many contracts offer no warranties and sell the products “as is.” Thereby, they have no obligation to fix problems or maintain product relevancy. For example, a disclaimer that the product is offered with no representation of fitness for any specific purpose provides little to compel a vendor to address an issue or problem.Many contracts include practice indemnification of the software vendor for a variety of issues. For example, some contracts do not warrant the clinical content or the ability of the software to record information, but pass risk of any problems to the practice through broad indemnity clauses. On a similar note, some business associate agreements have the practice indemnifying the business associate for inappropriate disclosures committed by the business associate.A number of EHR vendors will not commit to support HIPAA Security or Privacy standards or Certified EHR status.
